Sexual and reproductive health service knowledge and use among youth in the Kathmandu Valley, Nepal : influence of gender-power relations

Abstract

Background: Young peoples’ sexual and reproductive health is a major public health concern across the globe. This is especially so in developing countries like Nepal due to poor healthcare delivery system as well as harmful traditional socio-cultural values around gender roles and norms that remain ingrained in every sphere of private and social life. Aims: The aim of this body of research is to examine both gender-power relations amongst youth in Nepal and to examine knowledge of sexual and reproductive health (SRH), including access and utilisation services. The specific aims include examining the associations between socio-demographic factors and knowledge of SRH and uptake of sexual and reproductive health services. It also seeks to explore the factors associated with gender equitable norms in relation to sexuality and reproductive health. Methods: This research used a mixed methods approach, combing both quantitative and qualitative methods. For the quantitative research, data obtained from household level cross-sectional survey among 680 males and 720 females age 15 to 24 years. Qualitative data were obtained from 72 participants in eight focus group discussions and 11 in-depth interviews, conducted in the five major urban cities in the Kathmandu Valley. Results: The quantitative study found that young people’s knowledge about contraception, fertility and unwanted pregnancy risk was poor. After adjusting for socio-demographic factors, the main predictors of greater SRH knowledge were being single, having a higher level of education and sourcing information from radio. Although the vast majority of young men and women had heard about modern contraceptive methods, less than half reported knowledge of the most reliable long-acting reversible methods. Furthermore, a third of the young people interviewed had been sexually active, but 42% of them had not used Background: Young peoples’ sexual and reproductive health is a major public health concern across the globe. This is especially so in developing countries like Nepal due to poor healthcare delivery system as well as harmful traditional socio-cultural values around gender roles and norms that remain ingrained in every sphere of private and social life. Aims: The aim of this body of research is to examine both gender-power relations amongst youth in Nepal and to examine knowledge of sexual and reproductive health (SRH), including access and utilisation services. The specific aims include examining the associations between socio-demographic factors and knowledge of SRH and uptake of sexual and reproductive health services. It also seeks to explore the factors associated with gender equitable norms in relation to sexuality and reproductive health. Methods: This research used a mixed methods approach, combing both quantitative and qualitative methods. For the quantitative research, data obtained from household level cross-sectional survey among 680 males and 720 females age 15 to 24 years. Qualitative data were obtained from 72 participants in eight focus group discussions and 11 in-depth interviews, conducted in the five major urban cities in the Kathmandu Valley. Results: The quantitative study found that young people’s knowledge about contraception, fertility and unwanted pregnancy risk was poor. After adjusting for socio-demographic factors, the main predictors of greater SRH knowledge were being single, having a higher level of education and sourcing information from radio. Although the vast majority of young men and women had heard about modern contraceptive methods, less than half reported knowledge of the most reliable long-acting reversible methods. Furthermore, a third of the young people interviewed had been sexually active, but 42% of them had not used contraception at the time of first sexual intercourse. With respect to knowledge and understanding of sexually transmitted infections, our study demonstrated that youth reported significant gaps both in knowledge about Chlamydia, the most common STI, and between knowledge and practice. Of all respondents, less than one quarter had ever visited a health facility or doctor to seek SRH information or treatment. Our study revealed that women face extreme discrimination in spheres such as decision-making, education and household activities, and their mobility is restricted due to gender-related socialisation processes and power relations. The gender equitable men scale revealed that just over half of young people held moderately gender equitable attitudes, and that males expressed more gender equitable views than females. Being male and having at least secondary education were the two most important variables influencing attitudes towards gender equity. However we found that there was a significant difference between men and women in their relationship power with men found to have higher sexual relationship power and higher decision-making power than women in relationships. After adjusting for all the socio-demographic factors, a significant association was still found between sexual relationship power and education level. The qualitative findings support the quantitative findings providing rich information regarding the influence of gender power relations on youth sexual and reproductive health. Despite stringent controls on the mobility and activity of unmarried youth, particularly women, opportunities do exist for sexual relationships, sometimes with adverse consequences for young people’s health and lives such as early marriage and unwanted pregnancies. Conclusions: This study highlights knowledge, experience and practice of SRH, the risks youth take with their SRH, and service utilisation, with some notable differences between young men and women. Gaps in knowledge about fertility, contraception and STIs suggest that the information reaching youth is not adequate. There is an urgent need for better information to be disseminated through the media, and for improved education at public and non-government health facilities. Further large differences between knowledge and practice may reflect the lack of confidence in SRH services and the cultural and religious environment that restricts open expression of sexual issues, particularly for young women. The expansion of youth friendly services that ensure confidentiality has been demonstrated elsewhere to improve access and should be a model supported in Nepal. Although we were surprised to find that a large proportion of young people held gender-equitable attitudes, there still remains considerable gaps especially between men and women relating to negotiating sexual relationships and reproductive health.